805 Will Boone Rd . . DAVIE COUNTY HEALTH DEPARTMENT � 10-IS-q�
. ` ► Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028 �;��
(336)751-8760
f1,��Y �'8���� ��,�IPROVEMENT/OPERATION PERMIT
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Account #: 989900063 Tax PIN/EH#: 5756-06-1575 �,,�
Billed To: Larry McDaniei Subdivision Info: �5 ��il/ �0C/'�„�° ��GN
Reference Name: Janice or Larry McDaniei Location/Address: Will Boone Road-27028
Proposed Facitity: Resldence Property Size: 2.939 Acres
ATC Number: 2190
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater
system. An ALTTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this
Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with
Article 11 of G.S. Chapter 130A,Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type �jj�(,�S� #People #Bedrooms�_ #Baths�
Dishwasher:� Garbage Disposal: ❑ Washing Machine:�� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size ��� Type Water Supply �0 Design Wastewater Flow(GPD) Lj 6(� Site: New� Repair❑
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width� Rock Depth��Linear Ft�DO�
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.****
� �
Environmental Health Specialist's Signature: �) Date: /U�S� l ��
DCHD OS/99(Revised)
� .
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 989900063 Tax PIN/EH#: 5756-06-1575
Billed To: Larry McDaniel Subdivision Info: '
Reference Name: Janice or Larry McDaniel Location/Address: Wiil Boone Road-27028
Proposed Facility: Residence Property Size: 2.939 Acres
ATC Number: 2190
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S.Chapter 130A,Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWA R ONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: � Date: ��l,S�/9�
CERTIFICATE OF COMPLETION
**NOTE** 'The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit
has been installed in compliance with Article 11 of G.S.Chapter 130A,Section .1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any
given period of time.
/�e�,�
F
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Septic System Installed By: , 1 C I
Environmental Health Specialist's Signature: � Date:�/,�— ����
DCHD OS/99(Revised)
- � t . .
• • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PE I��t-�� � � �
Davie County Health Department � �� �
Environmental Health Section
P.O. Box 848 SEP 2 Q ���
Mocksville,NC 27028 ,
M (704) 634-8760 Er�v►Ror�rAEPlTAL HEA H
DAVIE COU��TY
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL �+�
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed �rl"L l rn��-I����c�v�S.�.�Contact Person___�r��J � V�-�1�C� m�'����C�
Mailing Address�-�• lr�'�C �]� Home Phone ���LQ — ����Q� c�
City/State/Zip �k�U ���Q.. , ��-o�-�l»� Business Phone ��P —`7S1' �I da-�
2. Name on PermidATC if Different than Above
Mailing Address City/State/Zip
3. Applicadon For: [ j Site Evaluation [ j Improvement Permit&ATC [�Both
4. System to Serve: [�House [ ]Mobile Home [ ]Business [ ]Industry [ j Other �f'�
�;;�
5. If Residence: #People #Bedrooms�� #Bathrooms � [rj Dishwasher[ ]Gazbage Disposal i;;:
;�
[y]�Washing Machine [ ]Basement/Plumbing [ ]Basement/No Plumbing
6. If Business/Other:Specify type �I 1� #People #Sinks #Commodes
#Showers #Urinals #Water Coolers
If Foodservice:#Seats Estimated Water Usage(gallons per day) ,
7. Type of water supply: Count City [ ]Well [ J Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [vj No '
If yes,what type?
EZ THER tl PLAT OR S Z TE PLAN
PROPERTY INFORMATION REQUIRED: ***IMPORTANT**'��'OF THE PROPERTY MUST BE �.
SUBMITTED WITH Ii�S APPLICATIOl�:
Property Dimensions: � 0���35F�C;W��DIRECTIONS(from ocksville)TO PROPERTY:
Tax Office PIN: #.�- p�F - �� � � J` Q 6 I � `�YS E�.�7 d�
Property Address: Road Name �� �� ��� �-tl � �(�M �— (JLt g ' �
�
City/Zip �M OC�CS V�`�Q_ T�� �-��; — i b D
If in Subdivision provide information,as follows: ��.1 (r� j � �J 6 o e�
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Name: � �-, G,� � S 6 r �—e /"a
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�
Section• Lot#: � � —
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This is to certify that the information provided is conect to the best of my knowledge. I understand that any permit(s) issued hereafter aze
subject to suspension or revocation,if the site plans or intended use change,or if t6e information submitted in this application is falsified or
changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized
Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned
by � `��`i L� ���r�c�c� . Sl�,r�to con testing procedures as necessary to determine the site suitability.
DATE � �o� a 9 SIGNATURE �� {��
Revised DCHD(06-96) .
THZS AREA M,41f $E USEb �OR �RttWINC7 iJOUR SZTE PL,4N: ;
C�t���-�
�e� �'�'►� c.�t� � r a�w�;� � —
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This map is for PERC TEST
and BUILDING PERMIT purposes
only. The Davie County
Tax Administrator's Office
� assumes no liability for any
information contained on this map
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32
` COUNTY-ID:L80000000401
� September 20,199910:17 AM
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Parcel Identification Number
0nB2 5756-06-1575
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(2. 82A)
1575
32�`
200 ` �
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Scale:l"_ ••••"•••"• September 20,199910:09 AM
, ,.. ,.
�• � ' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Heolth Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 989900063 Tax PIN/EH#: 5756-06-1575
Billed To: Larry McDaniel Subdivision Info:
Reference Name: Janice or Larry McDaniel Location/Address: Will Boone Road-27028
Proposed Facility: Residence Property Size: 2.939 Acres Date Evaluated: � C'
Water Supply: On-Site Well Community Public v
Evaluation By: Auger Boring '�� Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition L,
Slo e%
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH �' ��
Texture rou
Consistence �
Structure / . /i'
Mineralo ,'/ .�
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE � `' i r
SITE CLASSIFICATION: EVALUATION BY: Cc'�
LONG-TERM ACCEPTANCE RATE: I b OTHER(S)PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope
Texture
S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt
SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Mois
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
Wet
NS-Non sticky SS-Slightly sticky S -Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
tructure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineraloev
1:1,2:1,Mixed
Notes
Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
Saprolite-S(suitable),U(unsuitable)
Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification-S(suitable),PS(provisionally suitable),U(unsuitable) ,
LTAR-Long-term acceptance rate-gaUday/ft2
DC�ID OS/99(Revised)
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